Provider Demographics
NPI:1821348392
Name:CHARLES D WONG DO MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CHARLES D WONG DO MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:661-324-0300
Mailing Address - Street 1:PO BOX 2287
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93303-2287
Mailing Address - Country:US
Mailing Address - Phone:661-324-0300
Mailing Address - Fax:661-324-4095
Practice Address - Street 1:9500 STOCKDALE HWY
Practice Address - Street 2:SUITE 109
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-3620
Practice Address - Country:US
Practice Address - Phone:661-663-6550
Practice Address - Fax:661-663-6259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8787208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGT818AMedicare PIN